Organizations working to improve the healthcare system have long used claims data to understand the cost of care, verify the integrity of payments, and identify patients who may be at risk of developing chronic conditions.
Claims data has provided value, and it continues to do so. While I don’t think we should throw the baby out with the bathwater, using clinical data to run the business of healthcare is essential if we are going to evolve from being a system that treats sick people to a system that prevents people from getting sick.
In this day and age, where clinical data is readily available, it can no longer be considered the icing on the cake: It is the cake.
Clinical and claims data should both be used to get the fullest, most useful picture of a patient’s and a population’s health.
The virtues of claims data
Before I extol the virtues of clinical data, a quick nod to claims data. Claims data can give us things that clinical data cannot.
For one, it provides us with essential information about the cost of a patient’s care. It also offers important insights that can help create a fuller picture of a patient’s health status and behaviors that may affect their health status.
Clinical data shows us that a clinician prescribed a medication, but not whether a patient is taking that medication. Claims data gets us a step closer, as a claim submitted from the pharmacy can at least tell us that the patient picked up their medication.
Because claims data spans multiple healthcare organizations, it can tell us about past procedures, diagnoses, or preventative care that patients may not self report. Having additional background information on a patient can help clinicians make more informed decisions about their care.
The vices of claims data
When we think about improving the health of populations, one of the biggest pitfalls of claims data is that it’s only collected on insured patients. Some of the most vulnerable patients in our healthcare system are those who are uninsured. Without clinical data, those patients would be invisible.
In addition, claims data gives us a limited view of a patient’s health status. If a clinician sees a patient who complains of an injured finger and that patient is diagnosed with a broken finger, the claims data will show us the broken finger diagnosis, but it’s unlikely to show us that the patient's weight was up from baseline and that they had lower extremity edema during the visit, which could infer a bigger health concern.
Claims data is also time-lagged. We get data on a patient 30 to 60 days after that data was collected.
Clinical data can be sent, analyzed, and used for good in a matter of seconds—with a trusted intermediary like Moxe.
The power of clinical data
When we use clinical data as the primary data source for a patient—and claims data as complementary—we get a more comprehensive picture of a patient’s health status and how care can be optimized for that patient.
Clinical data is much timelier than claims, giving us an almost real-time picture of a patient’s health status. To put it another way, claims data tells us what happened, while clinical data tells us what is happening.
When we think back to the example of the patient with high blood pressure, the fuller picture that clinical data delivers would enable us to prevent a potential ER visit after the patient faints from severe hypertension.
Clinical data opens up a world of opportunity when we think about population health, closing care gaps, and reducing health inequities.
One example: When a newborn is delivered at a hospital, they should be seen by a pediatrician about two days after they are discharged. What happens to children who are uninsured and whose parents never establish care with a pediatrician? Unfortunately, many of these children will only be seen in the ER when they are severely ill.
With clinical data, state-run health programs could possibly track newborns to encourage their parents to: 1) establish care with a pediatrician and 2) take them for check-ups at the recommended early childhood intervals.
There are a myriad of use cases for clinical data that could allow for early intervention opportunities with at-risk populations.
Moxe’s role in baking the cake
Unlocking clinical data and getting it to the parties that need to use it is at the heart of what we do.
We believe that getting clinical data into the right hands, in the right format, at the right time will both drive down the cost of care and improve care quality. Effective interoperability is essential to improve every aspect of our healthcare ecosystem.
We acknowledge, however, that when we talk about getting clinical data into the right hands, we need to talk about safeguarding that same data with the utmost care.
Our biggest differentiator is that we marry connectivity with control. We don’t send clinical data out into the universe with a hope and a prayer: Our technology allows our customers to put the same controls on their data as if their star HIM team member was QAing it. (You can read more about our commitment to privacy-centric interoperability in a blog from one of Moxe’s other Mikes here.)
It’s just that we’re able to release that data significantly faster, with a full audit trail, upwards of a 98% member-to-patient match rate, and more. And that helps both payers and providers.
We believe in the power of clinical data—and in the importance of allowing provider organizations to maintain control over what data gets released, when, and to whom.
As a trusted, neutral intermediary, we are partnering with like-minded organizations to change our healthcare system for the good of patients, providers, payers and populations. And that is the real cake.
If you’d like to learn more about how Moxe gets clinical data into the right hands at the right time, all while safeguarding privacy and security, please drop us a line here. We’d love to hear from you!
About Mike: Mike Coyne is a proven leader with significant experience growing, scaling, and optimizing healthcare technology and information services businesses. In roles that include CEO, board member, advisor and practicing lawyer, Mike has overseen the successful growth of technology startups, health plans, and multi-billion dollar companies. At Moxe, Mike lends his extensive experience to advance our strategy, operations, and business development efforts to meet the evolving needs of our clients.